Registered Nurse Appeals And Grievances Coordinator

Under the direction of the Manager of Appeals and Grievances, the appeals nurse will analyze insurance claims and/or coverage for medical and behavioral health treatments, procedures or services. This position will be responsible for the day to day clinical reviews for all appeals and grievances.

Required:

• Registered nurse with a minimum of three (3) years of clinical experience in acute care, critical care, emergency medicine or a combination of clinical and utilization management experience in the health insurance industry.

• Strong clinical knowledge and understanding of health care delivery processes.

• Familiarity with healthcare claims including ICD 10, CPT, HCPC and revenue codes.

• Familiarity with state and federal healthcare regulations.

• PC and keyboarding proficiency; intermediate Microsoft Office Skills.

Desired:

• Experience working for a managed care organization.

• Experience working appeals and grievances.

• CMC.

Responsibilities:

• Works under limited supervision, evaluates and investigates all information using evidence based guidelines, company polices, BMS and CMS guidelines as well as individual patient considerations to ensure the provisions of safe, timely and appropriate healthcare services.

• Promotes effective use of resources and provides assistance to members in managing their health care across the continuum of care.

• Independently evaluates basic to complex medical claims and/or appeal cases and associated records by applying clinical, regulatory and policy and procedures knowledge and experience to assess the appropriateness of the service provided, length of stay and level of care.

• Summarizes medical information for physician review or external review.

• Generates appropriate written status of review to providers, members, and regulatory entities advising of status.

• Orients, trains and provides guidance to less experienced staff.

• Collaborates and corresponds with providers, members and various internal departments to ensure members are getting appropriate care.

• Keeps up to date on utilization management state and federal regulations, policies, practices which includes applicable coding.

• Reviews complaint and appeal letters from insurance commissioners.